You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > RECONSTRUCTIVE SURGERY Bilobed FlapsArticle Last Updated: Sep 19, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 9
  Author: Anthony P Sclafani, MD, Director of Facial Plastic Surgery, The New York Eye and Ear Infirmary; Professor of Otolaryngology, New York Medical College Anthony P Sclafani is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American College of Surgeons Coauthor(s): Andrew Jacono, MD, Chief, Section of Facial Plastic and Reconstructive Surgery, The North Shore University Hospital at Manhasset; Assistant Professor, Division of Facial Plastic Surgery, The New York Eye and Ear Infirmary, New York Medical College; Assistant Professor, Department of Head and Neck Surgery, Albert Einstein College of Medicine; Director, The New York Center for Facial Plastic and Laser Surgery Editors: Gregory Branham, MD, Vice-Chair, Director, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Saint Louis University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; David W Stepnick, MD, Associate Professor, Departments of Plastic Surgery and Otolaryngology-Head and Neck Surgery, Case Western Reserve University School of Medicine; Vice President, University Otolaryngology-Head and Neck Surgery, Inc; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: bilobed flaps, local flap, transposition flap, double transposition flap, cutaneous defect, bilobed rotational flap, facial reconstructive surgery, nasal tip defects INTRODUCTIONSection 2 of 9
  The bilobed flap is a double transposition flap commonly used in reconstruction of facial skin defects. The bilobed flap allows for the movement of more skin over a longer distance than that possible with a single transposition flap. This flap is especially useful when it is applied to facial areas where skin is less mobile (eg, nasal tip, temporal forehead), as it allows for reconstruction of the primary defect with skin of matching consistency and color. History of the ProcedureIn 1918, Esser first described the bilobed flap to repair nasal tip defects. He attributed the increased versatility of the flap to the reduced arc of rotation required by using 2 flaps to reconstruct the defect instead of 1. Zimany is generally credited with popularizing the use of the bilobed flap. He defined this as a flap consisting of 2 lobes separated by an angle and based on a common pedicle. INDICATIONSSection 3 of 9
The use of a bilobed flap is indicated when the tissue adjacent to a cutaneous defect is insufficiently mobile to close the defect without causing tissue distortion. RELEVANT ANATOMYSection 4 of 9
The bilobed flap is a random transposition flap because its blood supply does not arise from a segmental artery, and no defined pedicle is present. Blood supply to the skin is via musculocutaneous and cutaneous arteries that perforate subcutaneous tissue. These vessels ascend into the deep reticular and papillary dermis to supply deep and superficial microcirculatory plexus. Rich anastomoses of vessels within these plexus provide blood flow into the most distant portion of the flap. TREATMENTSection 5 of 9
Surgical therapyThe bilobed flap, as Esser first described, comprises 2 flaps identical in size and form and separated by angles of 90° (see Image 1). Skin is transposed over 180°. This transposition commonly results in a noticeable pincushion effect or trapdoor deformity, ie, domelike elevation or depression, respectively, of the flap relative to the surrounding skin. Esser's design results in prominent tissue protrusion (ie, dog-ear or standing cone) at the point of rotation. Modification of Esser's design has improved cosmetic results. In modified designs, the lobes are not identical in size. The larger flap is slightly narrower than the defect it has to fill, and the second flap is half the width of the larger flap. Their lengths are identical. Angles between the lobes are less than 90°. The second flap is often designed with an elliptical tip to facilitate closure of its resulting defect. Each flap is transposed over 45° (see Image 2). Wide undermining is used to reduce tension and pincushion effect. Images 3-6 show a bilobed rotational flap procedure performed on a cadaveric specimen. Intraoperative detailsAs with all local flap designs, take care to place incisions in relaxed skin tension lines. Raise the flap just deep to the subdermal plexus, leaving a small amount of subdermal fat on the undersurface of the flap. Position flaps in areas of increased tissue laxity. Postoperative detailsScar dermabrasion can be used after surgery, as in many reconstructive efforts, to improve the cosmetic result. Follow-upRemove permanent cutaneous sutures 5-7 days after surgery. COMPLICATIONSSection 6 of 9
Bilobed flaps are extremely reliable when used properly. Given proper flap design, partial or complete failure is unpredictable. Flaps designed with large length-to-width ratios increase the likelihood of distal compromise because of the limited ability of the microcirculation to adequately perfuse the distal flap. Thinner flaps tend to increase the risk of distal failure because thinning the flap and leaving insufficient adipose tissue can disrupt the deep microcirculatory plexus. Because thinning may be necessary to improve the cosmetic result (ie, to avoid a pincushion effect), judicious use is recommended. Typically, dog-ears occur when flap lobes are transposed. Moy et al described several useful ways to deal with this problem. A Burow triangle may be included in the flap design at the base of the defect (see Image 7). Two other methods can be used to repair dog-ear defects. Excess tissue can be excised from the flap base, or it may be excised from the skin adjacent to the flap. Some believe that the cosmetic result is superior when tissue is excised adjacent to the flap because it breaks up the long, inferior scar line. FUTURE AND CONTROVERSIESSection 7 of 9
Traditionally, bilobed flaps have been used in facial reconstructive surgery to repair defects of the lower third of the nose, including defects of the nasal ala, supratip, and nasal tip. The procedure can be designed with medially or laterally based flaps. Flaps based laterally on the sidewall of the nose are most useful for the reconstruction of nasal tip defects, whereas medially based flaps are more useful for repairing alar defects. In nasal reconstruction, bilobed flaps are most practical for defects less than 1.5 cm in diameter. Larger defects can pose a problem because of the limited ability to recruit lax donor skin from the upper nose. The bilobed flap can replace other common flaps in reconstructing the lower third of the nose. Although median and paramedian forehead flaps provide good skin color and texture, they require multiple procedures and revisions. The nasolabial flap also provides a good match, but it has limitations in reaching the nasal tip area, and it can distort the alar contour. Zitelli reviewed 400 cases of bilobed flaps in lower-third nasal reconstructions. He found that use of a 45° angle between flaps resulted in less of a pincushion effect, trapdoor deformity, and dog-ear formation. Zitelli recommends wide undermining and dermabrasion 6 weeks after surgery if needed. Bilobed flaps are frequently used for repairing defects of the temporal forehead. Primary closure and other local flaps can distort the eyebrow, scalp hairline, and lateral canthus of the eye. Use of the bilobed flap corresponds to the "Robin Hood principle," ie, borrowing from the rich laxity of the cheek and transposing it to the relatively poor inelastic temporal forehead without distortion. MULTIMEDIASection 8 of 9
REFERENCESSection 9 of 9
Article Last Updated: Sep 19, 2006 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
